I recently visited the Computer History Museum in Mountain View, California, in the heart of Silicon Valley. This museum chronicles the evolution of computing technology from slide rules to self-driving cars. Their exhibits showcase fascinating stories of what the power of the human mind can achieve. The tangible manifestations of these achievements on display played important parts in ending wars (the ENIGMA cipher machine or the Manhattan Project), walking on the moon, computer animation, the world-wide web, and today’s smartphones. These achievements required advances in engineering, math, sciences, art, language, and culture. However, the real stories behind the innovations on display are about the people who had the passion, curiosity, creativity, visionary leadership, and undaunted optimism for what could be achieved. These individuals have shaped history and influenced our current lives, but they have also created and thrived on uncertainty.
In 1989, I had a conversation about the future of optometry with a leader in the profession and in his community. His advice to me, as a budding professional, was to choose another path. The challenges were too great and the future looked too bleak compared to the fruits that he had enjoyed over his career. I was told that the opportunities before me were meager and getting worse compared to what they once were. Our conversation left me stunned, and for the last 25 years, I have never accepted this assessment. To provide a little context, at that time, corporations were exerting growing influence over independent practitioners and vision insurance programs were quickly becoming a way for practitioners to participate in the competitive business environment of the American healthcare arena. Medicare parity for optometry was achieved 2 years earlier, in 1987, and the use of therapeutic pharmaceutical agents was fast becoming established as the standard of practice across the United States. New graduates were increasingly drawn toward the treatment and diagnosis of ocular disease and away from the history and roots that had defined the profession for the last 30 years. In short, there was much uncertainty and there were many forces actively shaping the future of optometry that included business, health policy, science, and technology.
Technology was exerting its inexorable force then, just as it does now. In 1989, vision researchers were just 2 years away from introducing Optical Coherence Tomography (OCT). This technology has revolutionized retinal imaging and is continuing to do so today as OCT angiography promises label-free angiography. Amid much worry and concern, disposable contact lenses were introduced 2 years earlier, in 1987. The unprecedented direct-to-consumer marketing strategy that debuted with this medical device caused patients and practitioners to rethink their place and perceptions with respect to health services, and medical products. These advances in hydrogel lens manufacturing technology also spawned new clinical practices, new discoveries in factors associated with corneal inflammation and infection, and new insights on how patient behaviors influence contact lens outcomes. Advances in computer science also spawned advances in clinical practice. Mapping corneal shape in the 1950s and 1960s was a laborious computational task. Thanks to the advent of powerful personal computers in the late 1980s and early 1990s, corneal topography became a viable clinical tool for mapping corneal shape that would influence contact lens designs, orthokeratology, and keratoconus detection and also help fuel the growth of corneal refractive surgery. In 1988, a key patent for excimer lasers was issued that would lead to PRK and LASIK almost 10 years later. Forecasts then predicted there would be no need for glasses once this technology was established.
The 1989 Prentice Medal was awarded to David Maurice by the Academy of Optometry for his life-long accomplishments in ocular physiology. Although much of his work was related to corneal physiology, his lecture, The Physiology of Tears, was prescient. Now, 28 years later, tear physiology, ocular surface disease, and dry eye are major topics in eye research and clinical practice. This is an example of how investments in new directions, creative thinking, and fundamental research can spawn unanticipated growth and development that can change clinical practice.
So, what will come next and how will we respond? Unwilling or unable to adapt to the public’s transport expectations, taxi services in most major cities have felt the presence of Uber and Lyft who have evolved to fill the need for accessible and reasonably priced local transport. Online optical vendors are flourishing in response to consumer demands for value, shopping convenience, and service. Claims of better quality will not be sufficient to dissuade current trends. Warby Parker, the online-only eyewear retailer, opened for business in 2010, but in 2016 opened two brick and mortar retail shops in Chicago with a vision of eventually having 800 to 1000 stores. This hybrid strategy is a creative adaptation in response to the evolving environment. Eyewear vendors are also investing heavily in technology that will permit virtual trial and fitting of eyewear. Kiosks demonstrating endless frame styles can also make 3D measurements enabling custom designs and personalized optics. What are the opportunities created by challenging the status quo? What is the next disruptive innovation and how will we respond? Developing and harnessing technology in creative ways to address the needs and expectations of patients will continue to determine how clinical care is provided. A vibrant and engaged research community is essential to our future success, but evolution does not progress in a single direction, it is divergent. There is, however, a fundamental principle that can help one navigate:
It is not the strongest or the most intelligent who will survive but those who can best manage change.—Charles Darwin
Michael D. Twa
Optometry and Vision Science